Women's Knowledge, Expectations and Experience of

Induction of Labour

and the Association with Maternal Anxiety

Soheila Jadidi

A thesis submitted in accordance with the requirements

for admission to the degree of

MASTER OF MIDWIFERY (HONOURS)

UNIVERSITY OF TECHNOLOGY, SYDNEY

March 2012

CERTIFICATE OF AUTHORSHIP/ORIGINALITY

I certify that the work in this thesis has not previously been submitted for a degree nor

has it been submitted as part of requirements for a degree except as fully acknowledged

within the text.

I also certify that the thesis has been written by me. Any help that I have received in my

research work and the preparation of the thesis itself has been acknowledged. In

addition, I certify that all information sources and literature used are indicated in the

thesis.

Signature of Candidate

ACKNOWLEDGEMENTS

This research and the production of a thesis has taken me on a very challenging but

rewarding journey. I have learnt many things during this project and there are many

people to acknowledge and thank for their assistance and guidance in completing my

research study.

Firstly I would like to especially thank Maralyn Foureur, as my supervisor for your

tireless enthusiasm and standing beside me on the journey. Your speedy wonderful

feedback on my work has been particularly appreciated. Thank you for your support and

encouraging words when I needed them most. There have been many times when I did

not know how to express how grateful I am. To Caroline Homer, my co-supervisor,

thank you for your optimism and belief in my ability, the study and its importance to

society and health care. I am extremely grateful for the opportunity to have you both as

supervisors and mentors.

I would like to thank Georgina Luscombe for her great statistical help and valuable

suggestions throughout data analysis. My thanks also go to Julie Swain, whose

insightfuJ comments are greatly appreciated. Gratitude is extended to all maternity

managers and staff at Blacktown Hospital for their support, time and assistance.

Thank you to all the women for their participation and generously sharing their

pregnancy and birthing experiences and their valuable comments, in the hope of

improving health care for women and their infants.

Thank you to Mum, you have always supported me in everything I have done and for

this I am so grateful. Thank you to my daughters, Sogand and Niki, your support means

everything.

My acknowledgement and special thanks must go to Hamid, my best friend, my lover

and my soul mate. I thank you for your patience, understanding and unending belief in

me, for your constant support and encouragement, and for being the person who makes

life so worthwhile.

II

ABSTRACT

Induction of Labour (IOL) is one of the fastest growing procedures in childbirth in the

developed world with one in four women now being induced. The primary purpose of

this study was to further develop the understanding of women's knowledge,

expectations and experiences of IOL in order to identify whether women's views may

be contributing factors to the increasing rate of IOL. A descriptive and correlational

study design, using pre and post IOL surveys, captured the views of a convenience

sample of pregnant women booked for any type of IOL at Blacktown Hospital in 2009

and 2010. Consenting women were given self-administered, pre and post-IOL

questionnaires and the Spielberger State-Trait Anxiety Inventory. One hundred and nine

women experienced IOL and completed both pre and post IOL surveys; of these, 98

linked surveys were eligible to be analysed using SPSS v 18. Both simple descriptive

and multivariate analyses were undertaken.

The majority of participants (85.7%) acknowledged they agreed to have an IOL because

they were worried about problems with their baby if the pregnancy continued. Most

(59.1%) acknowledged a midwife as their most important care provider as well as the

most common source of information (61.2%). Although 96.9% of women expressed the

importance of information concerning IOL, only 75% were satisfied with the

information they received prior to the process. While the majority of participants

(97.9%) were satisfied with the care they received from midwives, overall, 13.4% did

not have a satisfying IOL experience.

More than 21% of women expected to give birth within six hours and only 15% of

participants expressed the length of their labour was around what they expected. While

7.1% came with no expectation regarding labour pain, 67.8% rated their pain as 'much

more/ more painful' than they expected.

These results revealed that many women did not have realistic expectations of IOL.

Satisfaction with childbirth was higher for women who had a birth experience that was

better than expected. In addition, there was a significant relationship between women's

realistic expectations and their satisfaction with IOL. However a positive relationship

between women's knowledge and their satisfaction with IOL was not found in this

study. There was a significant relationship between women's level of knowledge and

iii

their State anxiety level before undergoing IOL. Furthermore women who had more

realistic expectations were less anxious after experiencing IOL. Being well informed by

the midwife was the strongest predictor for satisfaction in this study (p<O.OO 1 ). In

addition those participants who had more realistic expectations were less anxious after

their IOL.

The results of this study add to our understanding of women's wishes and views

towards induction of labour within an Australian context. The importance of being well

informed by the midwife suggests a professional responsibility to ensure that women are

provided with accurate and timely information regarding IOL in order to set realistic

expectations to achieve a positive childbirth experience.

iv

TABLE OF CONTENTS

CERTIFICATE OF AUTHOR SHIP/ORIGINALITY ........ ............................................ i

ACKNOWLEDGEMENTS .......................................................... ............... ............. . ... ii

ABSTRACT ................................................................................................................ iii

LIST OF FIGURES ...................................................................................................... X

ABBREVIATIONS ............................................ ......................................................... xi

CHAPTER 1: INTRODUCTION .................................................................................. 1

MY POSITION IN THIS RESEARCH ............................................................................... 1

BACKGROUND TO THE STUDY AND SIGNIFICANCE OF THE ISSUE ............................... 3

DEFINITION OF IOL ....... ... ...... ... ... ... ............. ..... .... ......... ............ .... ..... ... .... .. ... .... . .... 5

A BRIEF HISTORY OF IOL.. ........... ..... ............................ ....... .... ................. ... .......... .. 5

Prevalence of IOL ..... ................................................................................................ 8

RISKS IN VOL YEO WITH IOL ... .... ... ....................................... ................................... 11

JOL increases requirement for pain relief .............................................................. I!

IOL increases continuous fetal monitoring and its attendant risks ......................... 12

IOL increases operative vaginal birth. .................. ....... ........ ...... .............. ............... 13

IOL increases the risk of caesarean section ............................................................ 14

IOL increases the risk of cord prolapse .................................................................. 17

!OL increases the risk of uterine h}perstimulation ... .............. ................... .... ......... 17

!OL increases the risk of uterine rupture ................... ............................................. 18

IOL increases the risk of postpartum haemorrhage (PPH) .................................... 18

IOL increases the risk of amniotic fluid embolism (AF£) ................ ....................... 18

IOL increases the risk o..f neonatal mortality and admission to neonatal intensive

care unit (NJCU) ..... ........ .......... ... ......................... .................................................. 19

Further complications and consequences ............................................................... 20

SUMMARY .............................................................................................................. 21

STRUCTURE OF THE THESIS ........... ............. ... .......... . .. .......... .............................. ..... 22

CHAPTER II: REVIEW OF THE LITERATURE ...................................................... 24

INTRODUCTION ........ ...... .......................... ............................................................... 24

SEARCHING THE LITERATURE .. .... .. ... .. ..... .. ............... ..... ... .... ......... ..... ........ .. ... ... .... 24

CONTEXTS OF CHILDBIRTH IN THE 20TH AND 21 ST CENTURIES .................. ............... 26

MATERNAL EXPECTATIONS AND SATISFACTION WITH THE BIRTH EXPERIENCE ....... 27

v

Maternal expectations ......................................... ...................................... .............. 28

Satisfaction with the childbirth experience ............................ ................................. 29

SIGNIFICANT VARIABLES ASSOCIATED WITH WOMEN'S EXPECf ATIONS AND

EXPERIENCE ..... ........... .. ........... .. ....................................................... .. ......................... 31

Feeling in control. ......... ................... ....................................................................... 32

Involvement in making decisions ............................................................................. 33

Support by a labour companion (partner/family/doula) .......... .. ............ .. ............... 34

Midwife-led care and continuity of care ....... .. .......................... .............. ... ............. 35

Being informed ........................................................................................................ 38

Obstetric interventions .......... ..................... .. .. ... ................ ... ......... .. ... ..... ......... .. ..... 41

Pain management ..... .... .... ....... ...... ........ ....... ... ......... ............................... .. .............. 43

MATERNAL ANXIETY AND ITS RELATIONSHIP TO WOMEN'S KNOWLEDGE,

EXPECTATIONS AND EXPERIENCE ....... ... ... . ...... ... ... ............................................ ...... ..... 45

MATERNAL RESPONSE AND ATTITUDES TO 10L ..... .. ............................................... .49

Seminal Studies of IOL .... .. ...... ............ .................................................................... 49

A MODIFIED REPLICATION OF A UK STUDY ............................ . ..... .... ... .. .... .. . . ......... 55

SUMMARY .............................................................................................................. 56

STUDY 1-IYPOTHESES ............................................................................................... 58

CHAPTER III: STUDY DESIGN AND METHOD ....... ............................................. 60

AIM OF THE STUDY . ..................... ....... ................ ........ ... ..... ....... ......... .... .......... ...... 60

DESIGN OF 1'HE S1'UDY ..... . ..... .... ....... .... .......... ..... .. ... ................. ..... .. .......... ........... 60

SETTING ............................................................................................ ..................... 60

DESCRIPTION OF THE SAMPLE.................... .. .................... .. .......... .... ...... ... . .... .. .. . ... 61

Culturally diversity and representativeness of the sample ..................................... 61

Sample size ..... .. ............ ... .... .... .... ..... ..... ......... .. ... .. ................ ...... ... .... ........... ... ....... 61

Inclusion criteria .......................... .. ......................................................................... 62

Exclusion criteria ......... ....... .......................................................................... .......... 62

Calculation of eligible population ..... ........ ........... ............. .. ................................... 62

DATA COLLECfiON PROCEDURE ... ... . . ... ....... . ... .. ....... . ... .. ....... . . .... .... ... .. .... . .. ....... .... 63

Routine practice at Blacktown Hospital.. ............................................................... 64

Participant recruitment ... .... .. ..... .. .. .... .... ....... .... ... .. .......... ... ..... ....... .. .... .. ...... .. ........ 64

Follow up procedure ............................................... ..... ... ..... ................................... 65

STUDY INSTRUMENTS ............ .. ...... ...... ... ........ .. .......... .. ........ ... ... ....... ............. ........ 65

vi

Piloting of the questionnaires in Australia ............................................................. 66

Final questionnaires ............................................... ................................ ................. 66

State-Trait Anxiety Inventory (STAI) ... ............... ................... ... .............................. 67

DATA ENTRY .......................................................................................................... 68

DATA ANALYSIS ...... . ............ .. ........... .......... ... .. ... ... . ... .......... . .................. .. ............. 68

Development of the analysis tools ... ......................................... ................ .. ..... ........ 69

Analysis of association between variables ......................... ................. .... ........ .. ...... 71

Predictors .. .... ... ........ .. ............... ..... ... ...... ...... ..... ............. .. ........... ....... ............ .... .... 71

Time o.f administration ........................................ .......... .............. ..... ...... ...... ...... ..... 71

ETHICAL CONSIDERATIONS ....... .. .. .. ....... .. .. .... ... ... . . ..... . .. ... . ..................................... 72

STUDY RESOURCES .... ............. . ............ .... .... .. ... . ........... .. ... ... ............ . ...... ...... . ...... . . 73

SUMMARY .. . ..... . .. ...... ......... .. ....... . .. .. ....... .. ........................... ... .............. . ................ 73

CHAPTER IV: RESULTS OF THE STUDY ............................................. ................. 74

INTRODUCTION .. ......... ... .... . ............ . .. ............ . . .. ......... . .. .......... ............. ....... . . . ... ..... 74

DESCRIPTION OF THE SAMPLE .. .. ........ . . .. .. ........... .. ......... . . ............. . ....... . .. . . . . ... ........ 7 4

Response rate ........... ............. ...... .. ............ ............................. ......... .... ................ .... 7 4

Demographic profile ... ........ .. ........ .. .... .. ....... ..... ... ...... ..... ...... .. ...... ... ..... ........... ...... . 75

Maternal baseline characteristics and expectations pre-IOL. ... ... .... .. .......... .... ... ... 77

Maternal experience of labour and birth. ...... ... ...... .... ...... ... ..... ... ... ... ...... ....... ..... ... 83

Women 's comments about their IOL experience ... .... .... ...... ... ..... ...... ....... ...... ........ 89

Maternal anxiety pre and post-IOL. .... ......... ...... .... ..... ... ..... .. ........ ... .. .. .. ... ....... .... ... 93

RESULTS FROM TESTING THE HYPOTHESES .......... .. ............. ........ ............ .. .............. 94

1) Hypothesis: There is an association between women's level of knowledge of

induction and their satisfaction level ............ .. ............ .. .... .. .. ... ...... ... ...................... 95

2) Hypothesis: There is an association between women's realistic expectations and

their level of satisfaction with childbirth .. .. ..... .. .. ........ .. ......................................... 96

3) Hypothesis: Satisfaction with childbirth is higher for women who have a birth

experience that is better than expected than for those who have a birth experience

that is worse than expected .......................................................................... ........... 96

4) Hypothesis: There is an association between women's level of knowledge of

induction and their State anxiety before the /OL process .. ........ .......... .... ... ... ........ . 97

5) Hypothesis: There is an association between women's level of knowledge of

induction and their State anxiety after the JOL process ....... ............. .... ......... .... .... 97

VII

6) Hypothesis: There is an association between women's expectations and their

State Anxiety level post-/0£. .............. ............ ......................................................... 98

VARIABLES THAT PREDICT EXPECTATIONS, KNOWLEDGE AND SATISFACTION .. ...... 99

Expectations regression model. .. ... ..... .... ............. .. .... ... ... .. .. ... .. .............................. 99

Knowledge regression model ... ..... .. .. ......... ...... ..... ...... ..... .................. .............. .... 100

Satisfaction regression model..... .... .. ....... ....... .. ........... .... .................. ... ... ..... .... .. . 101

SUMMARY .. ... .... .... ...... ...... .... ......... .. .......... ... ........... .. ............. ..... ........ .... .... ..... ... 101

CHAPTER V: DISCUSSION AND CONCLUSION ............ .. ............... .... ................ 103

INTRODUCTION ....... .. ........... .... ........ ... ... ....... ..... ........ ..... .... .... ... .. ..... ..... ........... .... 103

MATERNAL SATISFACTION WITH THE EXPERIENCE OF IOL .... ... .......... ... .......... ... .. 103

Future birth preference.. ......... ........ ... .......... ......... ....... ... ... .... ............ ... ..... ....... .. . 104

Having expectations met ......... ..... ............. .. .. .......... .. ......... ......... .... .............. ....... 104

Involvement in making decisions..... .......... ........ .... ..... .. .. ..... ........... ... .. ................ 105

State anxiety level post-/OL. .. ......... .... ... .. ......... ... ...... ..... ..... .... ............... .... ......... 106

Being inforJned. ... .. .. . .. .. .... .. .... ......... .. .. ... .. ..... .. ....... . .. .... ... .... . .. ... .. .... .. ..... ....... . ..... 106

Midwife-led care.. .. ..... ... .... ..... ..... ................ .... .... ......... ........ ...... ... ...................... 111

MATERNAL ANXJETY BEFORE AND AFTER IOL PROCEDURE.. ..... ... .......... .. ........ .. 112

Women's worries ... .... .. ..... ........ ......... ..... ..... .. ....... .. ... .. ...... ...... ......... .... .. .. .... ....... . 113

Women's wishes regarding /OL. .... .... .... ............ .. ............ .. ..... .. ... .... ... ... .... .. ..... .. . 114

Obstetric interventions ..... ... ... .... .... ... ... ..... .. .. ....... .............. ............ .... .................. 114

LIMITATIONS AND RECOMMENDATIONS...................... .... ................ ...... ....... ... ..... 115

IMPLICATIONS FOR MIDWIFERY RESEARCH ..... .... ... ......... ... ..... ..... .... ...... .. ... .. ....... 118

CONCLUSION.. .... ...... ... .... .... .... ................................................. ........ ..... ..... .... .... . 118

REI-'tRENCES ..... ... .. ... ............ .. .. ............................ ............ ........ .... ......... ... ... .. ... ..... 120

Appendix A: Hospital Booking Form ... ......... ... ....... .. ..... .. .... ... ............. ............. .. .. ..... 145

Appendix B: Inclusion criteria ..... ... ......... .. .. ... ..... .... ......... .. ........... ......................... ... 147

Appendix C: Exclusion criteria ........... ............. ........ ... .. .... .. .... ....................... ..... .... ... 149

Appendix D: Study information sheet ... ...................................................... ......... .. .... 151

Appendix E: Consent forms ............ .. ... .... ..... .......... ..... ....... ...... ...... .... ............. ... ....... 154

Appendix F: Study recruitment flow chart .. ....... ......... .... ... ...... ... ......... .............. .. ...... 160

Appendix G: Participants' labels ...... .... ... .. ... ......... .... .. ...... ............... .............. ........... . l62

Appendix H: Pre-induction questionnaire .... ..... ...... ....................................... ............ 164

viii

Appendix I: Post-induction questionnaire ..................... ........................ ... .................. 174

Appendix J: SW AHS HREC approval letter .... .. ........................................................ 182

Appendix K: UTS HREC approval letter ................................................................... 186

LIST OF TABLES

Table 1: Rates of women experiencing IOL in Blacktown Hospital 2005-2008 ...... .... . 62

Table 2: Calculation of eligible population in 2008** ................................................. 63

Table 3: Pre and Post-IOL Questionnaire Response rates ...... .......................... .. ...... .. .. 75

Table 4: Participant's demographics .. .. ........ .. ............................................ .. .. .. .......... . 76

Table 5: Maternal baseline characteristics and expectations pre-induction .......... ...... .. . 78

Table 6: Source of information (N: 98) ...... .. .. .... .. .. .. .. ...... .. .. .. ...... .. .............. ........ ....... 82

Table 7: Labour and birth data ........ ...... .................. .. .. .. ............ .. .... .. .. .. ............ .. ...... .. 84

Table 8: Pain relief during labour (N: 97) ...... ........ ...... .. ...... .. .. .. .... .... .......... .. .. .. .. .. .... . 85

Table 9: Comparison of the source of information (N: 98) .. ........ .... .. ................. .. .. ..... 86

Table 10: Induction of labour experience and satisfaction ..... .. ...... .. .. ....... ........ ........... 87

Table 11: The most frequent themes identified from the open-ended questions ... ...... .. 90

Table 12: Aggregated total score detail s for anxiety, expectations, knowledge and

satisfaction (N: 98) ....... .... ....... .. .. ... ... ... .. ... ..... ...... ... ... .... ... ............... .... .. ........ .. .. ....... . 95

Table 13: The association between women ' s ]evel of knowledge and their satisfaction .

.... .......... .... .... .......... ... .. ....... ........ .. ........ .. .............. ...... .. ..... ..... ............ .............. ........ . 95

Table 14: The association between women's level of expectation and their satisfaction

........... ...... ...... ...... .... ...... ...... ......... .......... ...... .......... .. ....... ......... ..... .. ... .. ....... ...... ....... . 96

Table 15 : The association between women' s level of knowledge and State anxiety level

pre-IOL ..... ..... ....... .. ........ ... ... ... .... .. ... ..... .. ... ... .. .... ... .. .. ... .. ...... .. ... ....... .. ................ ...... 97

Table 16: The association between women's level of knowledge and State anxiety level

post-IOL .... ..... .. .. ... ... .... .... .. ....... ... .. .. ..... ....... .. ......... ..... .. ......... .. .. ... .. ..... ..... .. ........ .. ... . 98

Table 17: The association between women' s level of expectation and their State anxiety

post-IOL .... .... ........ .. .. .. ... .... ..... .. ... ........... .. ...... ... .... ..... ...... .... ... ... .. ....... ... .. .. ... ... .... .. ... 98

Table 18: The regression models of predictors for women's expectations of IOL and

their satisfaction .. .... ... .... ........... ....... .... ...... ...... ...... ....... .... ...... .... ........... .... ... .. ..... .... 100

ix

LIST OF FIGURES

Figure 1 : State Anxiety level pre-IOL ................ ....... ............... ........... ............... .. ........ . 93

Figure 2: State Anxiety level post-IOL ................................ ......................................... 93

Figure 3: Trait Anxiety level ........................................................................................ . 93

X

ACOG

AFE

ARM

AWHONNC

CI

cs CTG

DIC

DOCs

EFM

FHR

GP

IOL

NICE

NICU

NHS

NSW

NSWDH

PG

PPH

PTSD

OR

RANZCOG

RCOG

RDS

SPSS

SROM

STAI

SWAHS

ABBREVIATIONS

American College of Obstetricians and Gynaecologists

Amniotic Fluid Embolism

Artificial Rupture of Membranes

Association of Women 's Health, Obstetric and Neonatal Nurses of Canada

Confidence Intervals

Caesarean Section

Cardiotocograph

Disseminated Intravascular Coagulopathy

Department of Community Services

Electronic Fetal Monitoring

Fetal Heart Rate

General Practitioner

Induction Of Labour

National Institute for Health and Clinical Excellence

Neonatal Intensive Care Unit

National Health Service

New South Wales

New South Wales Department of Health

Prostaglandin

Post Partum HaemmThage

Post Traumatic Stress Disorder

Odds Ratios

The Royal Australian and New Zealand College of Obstetricians and

Gynaecologists

Royal College of Obstetricians and Gynaecologists

Respiratory Distress Syndrome

Statistical Package for Social Sciences

Spontaneous Rupture of Membranes

State Trait Anxiety Inventory

Sydney West Area Health Service

xi

UK

US/USA

WHO

The United Kingdom

The United State of America

World Health Organization

xii